Anaesthesia and Intensive Care最新文献

Fellowship selection interviews evaluate candidates' suitability for specialised anaesthesia training. Applicants are not commonly provided with specific details of questions or topics although these are often sourced from previous applicants. This study explored whether increased transparency in the interview process, by providing a list of discussion topics beforehand, impacts applicant performance and experience. Data from 91 applicant interviews over four years (2021-2024) were analysed. The traditional interview format was employed in 2021 and 2022. A novel format was introduced in 2023, in which applicants were provided with a list of 14 discussion topics 3 weeks before the interview. 2024 interviews reverted to the traditional format. Applicant performance was compared across the study period, with feedback collected from the 2023 cohort. No significant difference in mean interview scores or variance ratios was found between the novel and traditional formats, nor between local and non-local applicants. A total of 58.3% of applicants preferred the novel format, citing reduced anxiety and improved preparation. One-third preferred the traditional format, arguing that transparency might disadvantage those who typically prepare for interviews independently. Interviewer feedback indicated no perceived disadvantages from increased transparency, and probing questions effectively elicited detailed responses without making answers seem rehearsed. Providing applicants with interview topics in advance did not impact overall ratings but positively affected their experience by reducing anxiety and improving perceptions of the interview process. The findings support the implementation of transparency in selection interviews to enhance fairness and candidate experience without compromising the validity of the selection process.

Nitrous oxide (N₂O) is ozone-depleting and a greenhouse gas. Studies have shown a high wastage of N₂O from leaking hospital infrastructure. Identifying leaks is a priority action in the Australian national health and climate strategy. Four possible methods to identify leaks have been described: the discrepancy method, cylinder weighing, pressure testing, and flow monitoring. We used the discrepancy and pressure testing methods to investigate possible N₂O leaks at St George Hospital, a large tertiary hospital in Sydney providing medical, surgical, birthing, paediatric, and trauma care. Our investigation was in four steps: (a) to determine how much N₂O is procured and calculate the associated carbon emissions; (b) to outline the location of pipeline supply; (c) to determine how much N₂O is used clinically (operating theatres, delivery suite, other areas); and (d) to assess for leaks throughout the pipeline using pressure testing. We estimated a total annual 'worst case' estimate of maximum possible clinical N₂O use of approximately 801,866 litres at St George Hospital in 2021, with 14,846 litres used in the operating theatres and 787,020 litres used in the delivery suite. This estimate was approximately 319,534 litres (or 28%) less than the 1,121,400 litres procured N₂O used to supply the manifold, indicating leaks at least this large. Pressure testing of the full manifold system identified leaks in three operating theatres. A substantial amount of the N₂O procured by St George Hospital is leaking to the atmosphere causing unnecessary emissions. This N₂O provides no benefits to clinical care, has financial costs, and may pose potential occupational exposure risks to clinicians.

Background: Arterial haemoglobin oxygen desaturation is common during gastroscopy and is associated with patient harm. Obesity increases the risk of desaturation during gastroscopy. High-flow nasal oxygen may reduce the risk of desaturation, but data are lacking.

Methods: We conducted a single-centre, parallel group, randomised controlled trial of high-flow nasal oxygen at 50-70 l/min compared with oxygen via nasal prongs 4-10 l/min, enrolling adults having gastroscopy procedures who had a body mass index greater than 30 kg/m². The primary outcome was the incidence of desaturation, defined as any peripheral oxygen saturation less than 90% during the procedure.

Results: We recruited 150 participants (75 in each group). The mean body mass index was similar in each group (35 vs. 36 kg/m²). High-flow nasal oxygen reduced the incidence of desaturation compared with standard oxygen therapy (three (4%) vs. 14 (19%), P = 0.005), and increased the median minimum peripheral oxygen saturation (98% (interquartile range 92-97%) vs. 94% (interquartile range 97-100%), P < 0.001). Fewer patients administered high-flow oxygen required airway interventions (39 (52%) vs. 58 (77%), P < 0.001), while the number of patients requiring interruption to the procedure for airway management were similar in each group (seven (9%) vs. five (7%), P = 0.57). High-flow nasal oxygen was associated with a higher risk of apnoea compared with standard oxygen delivery (17 (23%) vs. six (8%), P = 0.013), and a similar risk of arrhythmias existed between the groups (two (3%) vs. one (1%), P = 0.56).

Conclusion: High-flow nasal oxygen reduced the incidence of desaturation during gastroscopy in obese patients.

Acute kidney injury is a frequent complication in critically ill patients and often necessitates kidney replacement therapy. Optimising antimicrobial dosing in this population is essential yet challenging owing to altered pharmacokinetics in critical illness and the wide variability of prescriptions utilised in kidney replacement therapy. This case report investigates the pharmacokinetics of cefazolin in a critically ill patient receiving prolonged intermittent kidney replacement therapy, offering insights into dosing considerations in this clinical setting.

Airway management in critically ill patients remains an essential component of intensive care medicine and is associated with significant patient risks. We conducted a 6-year follow-up survey among intensive care unit (ICU) medical staff in Australia and New Zealand (ANZ) from June to September 2024 which explored current ICU airway management practices and compared these with our previous survey in 2019. Among 211 respondents (26% response rate), 79.6% were male and 70.6% were intensivists. Video laryngoscopy (VL) availability increased significantly to 100% (P=0.005). VL was the first-line choice for 82% of respondents (adjusted odd ratio (aOR) = 7.41; 95% confidence interval (CI): 4.33 to 12.67) and there was an increase in intubation checklist usage (aOR = 3.32; 95%CI: 1.88 to 5.86). The use of ketamine for induction doubled (33.2% versus 15.3%; aOR = 2.96; 95%CI: 1.65 to 5.31), and rocuronium (89.6%) was the most used neuromuscular-blocking agent. Only 15.1% consistently used a bougie or stylet, and half used bag-mask ventilation post-induction and prior to intubation. Only 54% of respondents were familiar with any guidelines, and less than half of respondents (46.4%) reported having any formal airway management training in the past 3 years. A majority (81%) supports mandatory airway management continuing professional development (CPD) for fellows of the College of Intensive Care Medicine of ANZ (CICM). Despite improvements in airway management among ANZ ICU clinicians, notable gaps persist between current practices and recent trial evidence and guideline recommendations, supporting the need for airway management CPD for CICM fellows.

Failing high-stakes examinations in specialist medical training has devastating effects on trainees, both personally and professionally, with some trainees requiring multiple attempts. Factors enabling the transition from failure to success are under-explored. This study aims to understand how intensive care trainees, taking multiple attempts at the final high-stakes exam for progression to specialist, made the transition from failure to success, and their lived experience of the journey. This qualitative study applied grounded theory design, conducting 11 in-depth interviews. All participants had had two or more failed attempts before achieving success in the final high-stakes examination, a critical hurdle in achieving Fellowship with the College of Intensive Care Medicine. Additional data included exam reports, an external review of the exam processes, and research notes. To achieve exam success participants needed to reconstruct their sense of self, develop a growth mindset and identify as a competent intensivist. The constructed theory, 'Identifying as an intensivist', relates to professional identity formation and 'thinking, acting and feeling' as an intensivist. 'Identifying as an intensivist' was integral to overcoming exam failure for intensive care trainees. Professional identity formation as an aspect of remediation for high-stakes assessments in medical specialty training has not been well described. Furthermore, assessment processes should be constructed to align with a professional identity reflecting the values and diversity of the specialty.

Little is known about the characteristics of potentially inappropriate or unnecessarily prolonged intensive care unit (ICU) admissions in Australia, nor the exposure rate of non-ICU clinicians to dying ICU patients. We conducted a single-centre retrospective cohort study at a university-affiliated hospital in Victoria, Australia, of patients admitted to the ICU between January 2022 and June 2023, who transitioned to end-of-life care during their ICU admission. Decisions regarding appropriateness were adjudicated during a bi-weekly morbidity and mortality meeting. Out of 287 patients 279 were included in the final analysis. One hundred and eight (39%) patients were deemed to have had a potentially inappropriate admission, and 37 (13%) were deemed to have had a potentially inappropriately prolonged admission. Significantly higher proportions of patients were admitted from either the ward (32.4% versus 22.4%, P=0.02) or another hospital (15.7% versus 6.4%, P=0.02) if they were deemed to have had a potentially inappropriate admission. Significantly higher proportions of patients deemed to have had a potentially inappropriately prolonged admission had treatment limitations (16.2% versus 40.5%, P=0.006), lower Australian and New Zealand Risk of Death scores (median score 27.2 versus 45.5, P=0.006) and a clinical frailty score of 5 or more (63.9% versus 45.1%, P=0.048). They also had a significantly longer median ICU length of stay (median length of stay 13.4 days versus 2.6 days, P <0.001) and received significantly higher rates of invasive supports such as tracheostomy (16.2% versus 1.2%, P <0.001). The four major themes linked to these admissions were 1) lack of planning/appropriate treatment limitations, 2) lack of recognition of dying, 3) issues with communication/consensus and 4) provision of highly invasive treatments. The median rate of exposure of individual ward-based clinicians was 1 dying ICU patient per 18 months. Early framing of goals of care, reassessment of treatment goals during an ICU admission, dedicated communication skills training, and embedded frailty assessments might reduce non-beneficial and prolonged ICU admissions.

Evaluation of the clinical learning environment in teaching hospitals is an important quality improvement metric. The measure for the anaesthesia theatre educational environment is a validated tool measuring the educational environment in the operating theatre, specific to anaesthesia. Monitoring the learning environment provides information about the impact of interventions, the influence of major events such as a global pandemic and is increasingly linked to accreditation requirements. This study was conducted to establish a baseline for monitoring the impact of interventions designed to improve the learning environment. We surveyed trainees at the Royal Melbourne Hospital, a trauma hospital in Melbourne, Australia, aiming to identify areas for improvement in the clinical learning environment and provide a needs analysis for interventions to help anaesthesia trainees set and achieve learning goals. This single centre survey study occurred over a 6-week period from May 2023. Medical staff who had undertaken a training rotation at Royal Melbourne Hospital in the past 6 months were eligible. Twenty-six responses were received (response rate 39%). Areas for improvement included setting learning goals (mean 3.9, median 5, interquartile range 4-5) and assessment of trainee performance (mean 3.8, median 4, interquartile range 3-5). Over 80% of participants had received no training in how to set a learning goal, despite over 90% indicating that it would be of value to their experience. Trainee perception of the learning environment was positive but there is opportunity for improvement. We are planning interventions to assist trainees and consultants to set learning goals while working in a dynamic clinical learning environment.

Simulation-based training can be valuable for teaching bronchoscopy to intensivists, providing a risk-free training environment. We developed, implemented and evaluated a simulation-based flexible bronchoscopy training program for intensive care Fellows and intensivists. This paper presents the development of its design and lessons learned. We used the Analyse, Design, Develop, Implement and Evaluate model for developing and evaluating the training program (Analysis and Design - phase 1, Development - phase 2, Implementation - phase 3, Evaluation - phase 4). In phase 1, two intensivists formulated learning objectives for bronchoscopy in an intensive care setting, which guided the identification and development of training materials and the preliminary training program (phase 2). In phase 3, we tested this program and gathered feedback from participants to guide program modifications. After implementing the adjusted training, we measured participants' satisfaction using a survey based on closed- and open-ended questions (phase 4). Fifty-seven participants attended the training, with 18 (32%) responding to the questionnaire. Respondents highly appreciated the training program, with median satisfaction scores of 4 or higher on a five-point scale for all closed-ended questions. Respondents appreciated the supervision and feedback and found the simulator equipment relevant for learning bronchoscopy. This description of the program's development and its evaluation results can serve as a valuable resource for those wishing to establish similar training programs. We recognise that further implementation of evidence-based instructional design principles might enhance the training program's scientific foundation and effectiveness. We therefore recommend a more evidence-based approach for the design of future bronchoscopy simulation training programs.